Section outline

  • Key unit Competencies

    Take appropriate decision on different common medical pathologies of cardiovascular

    system.

    Introductory Activity 1.0

    Observe the following schematic representation that shows the connection

    between the heart and blood vessels and answer the following questions:

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    Figure 2.1 Blood Circulation system.

    1. Basing on anatomy and physiology of the heart and circulatory system you
    learnt, what do you think may happen to the human being if the required
    cardiac output for better function of entire parts of the body changes are
    noted?
    2. What might be your interventions towards a patient with abnormal (low

    and high) cardiac output?

    1.1 HYPOTENSION

    Learning Activity 2.1

    Read carefully the case below and answer following questions:
    A 52 years old female patient presented with general weakness, headaches and
    occasional dizziness for the past three months. She had also had occasional
    abdominal discomfort, moderate anorexia and weight loss due to nausea. She
    tired more easily than before. She seemed frustrated and concerned about her
    condition. During the examination, the blood pressure was 94/55 mmHg (Normal
    systolic BP: 90-120mmHg/60-90 mmHg)), a regular pulse rate of 97 beats
    per minute (Normal pulse 60-80 beats per minute), and a normal abdominal
    examination. She was treated by some non-steroids anti-inflammatory drugs to

    relieve headache and sent back home.

    During the following week, she continued to have same clinical manifestations
    and decided to go back at health care setting. At arrival, blood pressure recheck
    confirmed a significant drop from 94/55mmHg to 84/45mmHg. She also continued
    to have headache associated with blurred vision. She was at that moment
    unable to stand due to dizziness, severe headache and body weaknesses.
    Her laboratory investigations revealed normal complete blood count with Hb:
    12.5mg/dl (Normal value Hb: 11-16mg/dl), ASAT: aspartate aminotransferasee:
    20U/l (Normal value: 10-30U/l), ALAT: alanine aminotransferase: 28U/l (10-40U/
    l), creatinine: 0.8mg/dl (0.2-1mg/dl). The decision of hospitalizing her was taken,
    prescribed the paracetamol 500mg three times per day for 3 days (painkiller)
    and Ringer lactate and Normal saline 1.5 liter/24 hours (intravenous fluids)
    and planned for further investigations to look for all possible causes of those
    persistent signs and symptoms.
    1. What are the abnormal signs and symptoms that the patient was
    presenting?
    2. From the case scenario, identify different investigations that have been
    requested and their results?
    3. Basing on those signs and symptoms, what could be the medical problem
    of this patient?
    4. What will be included in the medical and nursing management of this
    case?

    5. If not treated, what will be the consequences?

    The function of the cardiovascular system is to supply body cells and tissues with
    oxygen-rich blood and eliminate carbon dioxide (CO2) and cellular wastes. Damage
    and disease in the cardiovascular system greatly affect a person’s health and the
    entire parts of his/her body. Cardiovascular diseases are conditions and diseases
    that affect the heart and vasculature (blood vessels).
    A good blood circulation requires the good cardiac output related to the capacity
    of the heart to pump and the normal functionality of blood vessels that determine
    the peripheral resistance. Blood pressure is the force exerted by the blood from
    the heart against the walls of the blood vessels. It must be adequate to maintain
    tissue perfusion during activity and rest. The maintenance of normal blood pressure
    and tissue perfusion requires the integration of both systemic factors and local
    peripheral vascular effects. Blood pressure is primarily a function of cardiac output
    and systemic vascular resistance. Any condition that can have an impact on these

    two aspects might have an impact on the blood pressure.

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    Hypotension is a decrease in systemic blood pressure below accepted values.
    Even though there is no accepted standard hypotensive value, the blood pressure
    less than systolic of 90-120mmHg/diastolic of 60-90mmHg is considered as
    hypotension. The hypotension becomes a concern once pumping pressure is not
    sufficient to perfuse key organs with oxygenated blood. This leads to symptoms

    impacting the quality of life of a patient.

    Causes and Pathophysiology

    Blood pressure is determined by 2 major factors: cardiac output and total peripheral
    vascular resistance. The cardiac output is determined by stroke volume and heart
    rate. Therefore, any disease or pathology that impacts one or more of these factors
    will induce hypotension.
    Disease that reduces stroke volume or heart rate will decrease the total cardiac

    output of the heart, therefore decreasing the ability to generate blood pressure.

    Some medications including diuretics, calcium channel and beta blockers can
    cause hypotension by having impact on stroke volume and heart rate.
    A combination of the weakened autonomic nervous system and mild hypovolemia
    from dehydration causes orthostatic hypotension. When lying flat, there is equal
    and smooth distribution of fluid throughout the body. However, on standing the
    heart rate fails to increase appropriately and peripheral resistance fails to increase
    appropriately leading to a rapid, transient decrease in blood pressure that improves
    with postural changes, then classic symptoms like dizziness and syncope occur.
    Certain conditions can cause prolonged periods of hypotension that can become
    dangerous if left untreated: pregnancy, due to an increase in demand for blood
    from both mother and the growing fetus; large amounts of blood loss through injury;
    impaired circulation caused by heart attacks or faulty heart valves, weakness and
    a state of shock due to dehydration, anaphylactic shock due to a severe form
    of allergic reaction, infections of the bloodstream, endocrine disorders such as
    diabetes, adrenal insufficiency and thyroid disease. Nutrient deficiency like lack of
    vitamin B12 and folate can cause low blood pressure due to reason that nutrients
    are essential to produce the red blood cells and their deficiency can lead to drop in
    blood pressure levels.
    Hypotension as a result of troubles of the factors determining the blood pressure,
    when persistent the patient might be into different types of shock:
    Distributive shock occurs as a failure of the ability to maintain total peripheral
    resistance with maintained cardiac function attempting to compensate. This is
    associated with anaphylactic allergic reactions and septic shock.
    Cardiogenic shock is a failure to achieve sufficient cardiac output with maintained
    total peripheral resistance.
    Hypovolemic shock is a loss of total blood volume such that a blood pressure is
    not maintained. Both cardiac output and total peripheral vascular resistance are
    maintained. This is possible due to trauma with massive loss of blood, overuse of
    diuretic medications with fluid volume loss via urine, burns, diarrhea and vomiting,
    hemorrhage, etc.
    Obstructive shock occurs with the obstruction, constriction, or compression of the
    cardiovascular system such that blood flow does not efficiently occur or there is a

    decrease in stroke volume of the heart. This leads to drop in blood pressure.


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    Signs and symptoms
    Patient with hypotension is most commonly asymptomatic. The chronic asymptomatic
    hypotension isn’t usually harmful. But there are possibilities that sudden drop in
    blood pressure may develop several health problems. The most common symptoms
    are lightheadedness or dizziness. In extreme low blood pressures, syncope may
    occur. Other symptoms are possible which typically begin from the underlying
    etiology rather than hypotension itself. They may include chest pain, shortness of
    breath, irregular heartbeat, headache, fatigue and weakness, pale skin color, rapid
    breathing, blurred vision, fainting when having syncope, nausea, rapid pulse rate,

    etc.

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    Investigations
    The investigations to be requested depend on the suspected cause. Basic lab work
    including complete blood count (CBC), cardiac enzymes, renal function tests (urea
    and creatinine), liver function tests, blood smear for malaria, blood sugar levels,
    electrolytes (sodium, potassium, chloride, calcium, etc). If a patient present signs
    and symptoms of shock, all these investigations must be ordered among others:
    chest x-ray, electrocardiogram, blood culture, urine culture, ultrasound of the heart,
    chest computerized tomography scan with angiography, etc).
    Adequate Medical diagnosis
    The diagnosis of hypotension requires relying on clinical manifestations supported
    by laboratory and imaging investigations, and hemodynamic findings. Imaging or
    hemodynamic indices of low cardiac output or systemic vascular resistance are not
    diagnostic but may help to classify hypotension.
    Treatment plan
      Asymptomatic hypotension patient should not receive extreme interventions.
      However, if symptoms are present, the treatment of hypotension should focus on
       reversing the underlying etiology. The management must focus on:
    • Patients should be assessed (monitoring of all vital signs) for possible need
       for an immediate intervention so that lifesaving therapies can be administered
       very early. After immediate stabilization, the comprehensive physical
       examination must be followed.
    • The airway should be stabilized and adequate intravenous access secured
       so that patients can be immediately treated with intravenous fluids to restore
       adequate tissue perfusion. The first priorities must be focused on the airway
       and breathing with oxygen and/or mechanical ventilation, when necessary;
       and insertion of intravenous catheter and IV fluids (Normal saline or Ringer
       lactate) must be initiated to restore adequate tissue perfusion.
    • Ensure the investigations needed are done to investigate the suspected
       cause of hypotension
    • Monitoring the inputs and outputs
    • Treat underlying medical conditions, and this should include medications for
       heart disease, diabetes, or infection. Patients with suspected infection (eg,
       fever, hypotension, and a suspected septic source) must benefit from the
       early administration of intravenous antibiotics.
    • Shock-induced hypotension is the most serious form of the condition. Severe
       hypotension must be treated immediately, should give IV fluids and possibly
       blood products to increase the blood pressure and stabilize the vital signs and
       hemodynamic status.
    • Advise the patient to drink plenty of water to avoid hypotension due to
       dehydration, especially if you are vomiting or have diarrhea. Staying hydrated
       can also help treat and prevent the symptoms of mediated hypotension. If
      you experience low blood pressure when standing for long periods, be sure
      to take a break to sit down. And try to reduce your stress levels to avoid
       emotional trauma.
    • Treat orthostatic hypotension with slow, gradual movements. Instead of
       standing up quickly, work your way into a sitting or standing position using
       small movements. Avoid orthostatic hypotension by not crossing the legs
       when you sit.
    • Exercise regularly aiming at raising the heart rate and resistance exercises
       two or three days a week.

    Evolution and complications

    The prognosis of hypotension is very good, but symptomatic hypotension might
    have variable prognosis depending on the etiology and its severity.
    Some complications resulting from Hypotension are:
    • Shock depending on etiology of hypotension
    • Injury resulting from falls due to fainting. Falls are particularly dangerous
      because they cause other secondary injuries (fractures, lacerations, wounds,
      limited movements, etc.) that might have an impact on a person’s quality of
      life.
    • Severe hypotension deprives the body of oxygen, which can damage the
       heart, brain, kidney and other organs (multiple organ dysfunction); and this

       condition can be life threatening if not immediately treated.

    Self-assessment 2.1

    1. What are the signs and symptoms of hypotension?
    2. What are the possible causes of hypotension?
    3. What are the investigations for the patient with hypotension?
    4. What is the most appropriate treatment for hypotension?
    CASE STUDY
    Carefully read the case scenario below and answer the following
    questions:
    K.L., a 25 year old man, was not wearing his seat belt when he was the driver
    involved in a motor vehicle crash.
    K.L. was found 10 meters away from his car and was crying. His wife and daughter
    were found in the car with their seat belts on. They sustained no serious injuries,
    but were upset. All passengers were taken to the emergency department. He
    states that he can’t breathe and cries when abdomen is palpated. His vital signs
    were: temperature of 37.6oC blood pressure of 80/56 mm Hg; apical pulse 138 but
    no palpable radial or pedal pulses; carotid pulse present but weak. Respiratory
    rate 38 cycles/min; oxygen saturation of 86% on room air and asymmetric chest
    wall movement; he had slight distended and left upper quadrant pain on the
    abdomen. He had open wound of the lower left leg.
    1. What is the medical condition is K.L. experiencing?
    2. What clinical manifestations did he display that support your answer?
    3. What would be included into this patient’s comprehensive assessment?
    4. What investigations would you advise to be done to K.L to confirm the
    medical condition? Justify the rationale of them.
    5. What are the nursing interventions towards for K.L. medical condition?
    6. After stabilization of K.L, what will be included into his medical and nursing
    management?

    7. What are the possible complications related to K.L medical condition?

    2.2 HYPERTENSION

    Learning Activity 2.2

    H.E. is a 45-years-old man with 88Kgs and 1.60m (obese) presented at a health
    clinic and was found having the blood pressure of 170/95 mmHg (Normal BP:
    90-120mmH/60-90mmHg). His father died of stroke at age 80 years; the mother
    is alive but has hypertension. He states that he feels fine except the headache,
    dizziness, chest pain especially during physical activities. He smokes one pack
    of cigarettes daily for the past 28 years. He drinks 1-2 bottles of beer on most
    Friday and Saturday nights. From the Laboratory investigations, he had full blood
    count with Hb of 14mg/dl (Normal range 11-16 mg/dL), triglycerides of 350mg/
    dl (Normal value: <150 mg/dL), sodium of 143 mEq/l (Normal range: 135-145
    mEq/l). His care provider prescribed the hydrochlorothiazide 12.5 mg/day and
    gave him the appointment to come back at clinic once a month.
    1. From the case described above, what are the abnormal signs and
    symptoms was he presenting?
    2. What type of information you may ask the patient, family members to
    guide in diagnosis?
    3. What do you think is the medical condition of H.E?
    4. Enumerate all risk factors that predisposed H.E for developing that
    medical condition.
    5. What are the investigations that have been requested to H.E?
    6. What are different medical and nursing management options are effective
    in managing H.E medical condition?
    7. H.E. wants to know the most effective preventive strategies for lifestyles
    changes to lower his blood pressure. What will be the content of lifestyles
    modifications would you tell him?
    8. What do you think will happen to H.E if there is poor adherence to

    prescribed treatment regimen?

    The blood pressure reflects the ability of the arteries to stretch and fill with blood,
    the efficiency of the heart as a pump, and the volume of circulating blood. Blood
    pressure is affected by age, body size, diet, activity, emotions, pain, position,
    gender, time of day, and disease states.
    All these factors can have an impact on lowering or increasing the blood pressure.
    Hypertension, or high blood pressure, is an important medical and public health
    problem.

    There is a direct relationship between hypertension and cardiovascular disease.


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    Hypertension is a repeatedly elevated blood pressure exceeding the 90-120mmHg
    as systolic and 60-90mmHg of diastolic pressure. When measuring the blood
    pressure, we are looking for the pressure during systole and diastole, and is
    expressed as a fraction. The top number is the systolic blood pressure; the bottom

    number is the diastolic blood pressure.

    A. Systolic Blood Pressure

    Systolic blood pressure is determined by the force and volume of blood that the left
    ventricle ejects during systole and the ability of the arterial system to distend at the

    time of ventricular contraction.

    B. Diastolic Blood Pressure

    Diastolic blood pressure reflects arterial pressure during ventricular relaxation
    where the heart is being filled by blood either from his automatism functionality or

    from venous return.

    Classification of blood pressure for Adults age 18 years or older

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    The term hypertension, sustained elevations in systolic or diastolic blood pressure

    that exceed prehypertension levels, is divided into two categories:

    Stage 1 hypertension: is systolic blood pressure of 140 to 159 mm Hg or a diastolic
    blood pressure between 90 and 99 mm Hg.
    Stage 2 hypertension: is systolic blood pressure that equals or exceeds 160 mm

    Hg or a diastolic pressure that equals or exceeds 100 mm Hg.

    Other terminologies:
    When elevated blood causes a cardiac abnormality, the term hypertensive heart
    disease is used. When vascular damage is present without heart involvement, the

    term hypertensive vascular disease is used.

    When both heart disease and vascular damage accompany hypertension, the

    appropriate term is hypertensive cardiovascular disease.

    Causes and pathophysiology overview

    A. Causes and Risk Factors

    Basing on causes and risk factors, hypertension is divided into two main categories:
    essential (primary; idiopathic) and secondary.
    Primary (essential or idiopathic) hypertension: represent about 90-95% of all
    hypertension cases. It is sustained elevated blood pressure with no known cause.
    Although the exact cause of primary hypertension is unknown, there are several
    contributing factors which include increased sympathetic nervous system activity,
    overproduction of sodium-retaining hormones and vasoconstricting substances,
    increased sodium intake, overweight, diabetes mellitus, tobacco use, and excessive

    alcohol consumption.

    Essential hypertension also may develop from alterations in other body chemicals
    such as defects in blood pressure regulation resulting from an impairment in the
    renin-angiotensin-aldosterone mechanism.
    Secondary hypertension: is elevated blood pressure with a specific cause that often
    can be identified and corrected. It results from some other disorders such as kidney
    disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism
    (increased secretion of mineral corticoid by the adrenal cortex), atherosclerosis,
    use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and
    use of oral contraceptives. This type of hypertension accounts for 5% to 10% of all
    hypertension cases. It should be suspected in people who suddenly develop high
    blood pressure, especially if it is severe.
    Treatment of secondary hypertension is aimed at removing or treating the underlying
    cause. Secondary hypertension is a contributing factor to hypertensive crisis.
    Hypertension is the most prevalent modifiable risk factor for most of cardiovascular
    diseases, being more common than cigarette smoking, dyslipidemia, or diabetes,
    which are the other major risk factors. Hypertension often coexists with these other
    risk factors as well as with overweight/obesity, an unhealthy diet, and physical
    inactivity. The presence of more than one risk factor increases the risk of adverse

    cardiovascular events.

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    B. Pathophysiology Overview


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    Hypertension results from a sustained increase in peripheral resistance (arteriolar
    vasoconstriction), an increase in circulating blood volume, or both. Chronic
    hypertension damages the walls of systemic blood vessels.


    Signs and symptoms

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    Hypertension is often called the silent killer because it is frequently asymptomatic
    until it becomes severe and targeted organ disease occurs. A patient with severe
    hypertension may experience a variety of symptoms secondary to the effects on
    blood vessels in the various organs and tissues or to the increased workload of
    the heart. These secondary symptoms include fatigue, dizziness, palpitations,
    angina/chest pain, and dyspnea. Headache, nosebleeds and bleeding from other
    organs might come when the blood pressure is very high. However, patients with
    hypertensive crisis may experience severe headaches, dyspnea, anxiety, and
    nosebleeds.
    Investigations
    Most hypertension is not classified as primary hypertension, testing for secondary
    causes should be routinely done. Basic laboratory studies are performed to:
    • Identify or rule out causes of secondary hypertension,
    • Evaluate target organ disease,
    • Determine overall cardiovascular risk, or
    • Establish baseline levels before initiating therapy.
    Basic diagnostic studies performed in a person with hypertension are the following:
    1. Full blood count (FBC) to assist in establishing the baseline levels before
         initiating the therapy or detect infection if any.
    2. Routine urinalysis, bilirubin urea and nitrogen (BUN), liver function tests
        (ASAT, ALAT) and serum creatinine levels used to screen for renal and
        liver involvement and to provide baseline information about kidney and liver
        function.
    3. Measurement of serum electrolytes (sodium, potassium, chloride), especially
        potassium, is important to detect hyperaldosteronism, a cause of secondary
       hypertension.
    4. Blood glucose levels (serum glucose) assist in the diagnosis of diabetes
        mellitus.
    5. A lipid profile (total lipids, triglycerides, cholesterol) provides information
        about additional risk factors related to atherosclerosis
    6. Uric acid levels establish a baseline, since the levels often rise with diuretic
        therapy.
    7. An electrocardiogram (ECG) provides baseline information about cardiac
        status. It can identify the presence of cardiac ischemia, or previous
        myocardial infarction, etc.
    8. Ophtalmic examination: may reveal vascular changes in the eyes, retinal
        hemorrhages, or edema of the optic nerves, known as papilledema.

    Adequate medical diagnosis of Hypertension

    Blood pressure measurement is the initial strategy and the gold standard to

    confirm the diagnosis of hypertension in most patients. In practice, blood pressure

    measurement is simple and quick and should be performed at every clinical

    encounter.

    When hypertension is suspected or confirmed based on blood pressure readings,

    a physical examination and all related investigations should be performed to

    determine the extent of target-organ damage if any. Look for the presence of

    cardiovascular or kidney disease, the presence or absence of other cardiovascular

    risk factors, lifestyle factors that could potentially contribute to hypertension,

    potential interfering substances (eg, chronic use of nonsteroidal antiinflammatory

    drugs, estrogen-containing oral contraceptives) that can lead to hypertension.

    The physical examination should include the funduscopic examination to evaluate

    for hypertensive retinopathy and must be able to detect/predict all other possible

    complications.

    Treatment plan
    Goals include achieving and maintaining normal blood pressure and reducing
    cardiovascular risk and target organ disease. This treatment plan includes lifestyle
    modifications and medications:
    1. Weight reduction: overweight persons have an increased incidence of
    hypertension and increased risk for cardiovascular diseases. When a person
    decreases caloric intake, sodium and fat intake are usually also reduced.
    Although reducing the fat content of the diet has not been shown to produce
    sustained benefits in blood pressure control, it may slow the progress of
    atherosclerosis and reduce overall cardiovascular diseases risk.
    2. Dietary sodium and potassium reduction: this involves avoiding foods
    known to be high in sodium and not adding salt in the preparation of foods
    or at meals.
    3. Avoid/Moderation of alcohol consumption,
    4. Regular physical activity: physically active lifestyle is essential to promote
    and maintain good health. Physical activity is more likely to be done if it is
    safe and enjoyable, fits easily into one’s daily schedule, and is inexpensive.
    People with hypertension must increase their physical activity. Advise
    sedentary people to increase activity levels gradually.
    5. Avoidance of tobacco use (smoking and chewing), and
    6. Management of psychosocial risk factors.
    7. Medications: the drugs currently available for treating hypertension have
    two main actions: (1) they decrease the volume of circulating blood and (2)
    they reduce systemic vascular resistance. The drugs used in the treatment of
    hypertension include diuretics, the adrenergic inhibitors, direct vasodilators,

    angiotensin and renin inhibitors, and calcium channel blockers.

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    Key nursing interventions:

    1. Health promotion: Primary prevention of hypertension is a cost-effective
        approach. Current recommendations for primary prevention include lifestyle
        modifications that prevent or delay the rise in blood pressure in at-risk people.
    2. Blood Pressure Measurement: Initially, take the blood pressure in both
        arms to note any differences. Proper size and correct placement of the blood
        pressure cuff are critical for accurate measurement.
    3. Screening Programs: screening programs in the community are widely
        used to check individuals for high blood pressure. At the time of the blood
        pressure measurement, give each person a written, numeric value of the
        reading. If necessary, explain why further evaluation is needed. Effort and
        resources should focus on the following: (1) controlling blood pressure

        in persons already identified as having hypertension; (2) identifying and

    controlling blood pressure in at-risk groups such as obese people, and
    relatives of people with hypertension; and (3) screening those with limited

    access to the health care system.

    4. Monitoring of Patient Adherence to medications and regimen: A major
    problem in the long-term management of the patient with hypertension
    is poor adherence with the prescribed regimen. The reasons for poor
    adherence include inadequate patient teaching, unpleasant side effects of
    drugs, return of blood pressure to normal range while on medication, lack
    of motivation, high cost of drugs, lack of insurance, and lack of a trusting
    relationship between the patient and the health care provider.
    Also assess the patient’s diet, activity level, and lifestyle as additional
    indicators of adherence. Individually assess patients to determine the
    reasons why the patient is not adhering to the treatment and develop a
    plan with the patient to improve adherence. The plan should be compatible
    with the patient’s personality, habits, and lifestyle. Active patient participation
    increases the likelihood of adherence to the treatment plan. Measures
    such as including the patient in the development of a medication schedule,
    selecting medications that are affordable, and involving caregivers help
    increase patient adherence.
    Substituting combination drugs for multiple drugs once the BP is stable may
    also facilitate adherence. Combination drugs reduce the number of pills the
    patient has to take each day and may reduce costs. It is important to help
    the patient and caregiver understand that hypertension is a chronic illness
    that cannot be cured. Emphasize that it can be controlled with drug therapy,
    diet changes, physical activity, periodic follow-up, and other relevant lifestyle
    modifications.

    Evolution and complications of hypertension

    Hypertension is associated with a significant increase in risk of adverse cardiovascular
    and kidney outcomes. Each of the complications is closely associated with the

    presence of hypertension.

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    Complications of hypertension
    Regardless of whether a person has essential or secondary hypertension, the
    accompanying organ damage and complications are the same. Hypertension
    causes the heart to work harder to pump against the increased resistance. The extra
    work and the greater mass increase the heart’s need for oxygen. If the myocardium
    doesn’t receive sufficient oxygenated blood, myocardial ischemia occurs and the

    client experiences angina. Consequently, the size of the heart muscle increases.

    When the heart no longer can pump adequately to meet the body’s metabolic needs,
    heart failure occurs. In addition to its direct effects on the heart, high blood pressure
    damages the arterial vascular system. It accelerates atherosclerosis. Furthermore,
    the increased resistance of the arterioles to the flow of blood causes serious
    complications in other body organs, including the eyes, brain, heart, and kidneys.
    Hemorrhage of tiny arteries in the retina may cause marked visual disturbances
    or blindness. A cerebrovascular accident (stroke) may result from hemorrhage or
    occlusion of a blood vessel in the brain. Myocardial infarction (MI) may result from
    occlusion of a branch of a coronary artery. Impaired circulation to the kidneys may

    result in renal failure.

    In summary, the complications of hypertension are:
    – Hypertension emergency
    – Atherosclerotic coronary artery disease
    –Myocardial ischemia/ infarction
    – Heart failure
    – Renal Failure
    – Stroke/ Cerebral hemorrhage/ Cerebral ischemia
    – Aortic aneurysm
    – Retinal vascular sclerosis

    – Gangrene of extremities

    Hypertensive Crisis:

    Hypertensive crisis is a term used to indicate either a hypertensive urgency or
    emergency. This is determined by the degree of target organ disease and how
    quickly the blood pressure must be lowered.
    A hypertensive emergency develops over hours to days. It is a situation in which
    a patient’s blood pressure is severely elevated (often above 220/140 mm Hg) with
    clinical evidence of target organ disease. It can cause encephalopathy, intracranial
    or subarachnoid hemorrhage, acute left ventricular failure, myocardial infarction,
    renal failure, dissecting aortic aneurysm, and retinopathy.
    Hypertensive urgency develops over days to weeks. This is a situation in which a
    patient’s blood pressure is severely elevated (usually above 180/110 mm Hg), but
    there is no clinical evidence of target organ disease.
    Prompt recognition and management of hypertensive crisis are essential to decrease
    the threat to organ function and life. Hypertensive crisis occurs more often in patients
    with a history of hypertension who have not adhered to their medication regimens
    or who have been under-medicated. In such cases, rising blood pressure is thought

    to trigger endothelial damage and the release of vasoconstrictor substances.

    Clinical Manifestations

    A hypertensive crisis is often manifested as hypertensive encephalopathy, a
    syndrome in which a sudden rise in blood pressure is associated with severe
    headache, nausea, vomiting, seizures, confusion, and coma. Patients can have
    chest and back pain, dyspnea, and possibly reduced or absent pulses in the

    extremities.

    Management of Hypertensive crisis:
    Blood pressure level alone is a poor indicator of the seriousness of the patient’s
    condition. It is not the major factor in deciding the treatment for a hypertensive
    crisis. The link between elevated blood pressure and signs of new or progressive
    target organ disease determines the seriousness of the situation. Hypertensive
    crisis require hospitalization, intravenous administration of antihypertensive drugs

    and intensive care monitoring.

    Self-assessment 2.2

    1. What is included in the correct technique for BP measurements?
    a. Always take the BP in both arms.
    b. Position the patient supine for all readings.
    c. Place the cuff loosely around the upper arm.

    d. Take readings at least two times at least 1 minute apart.

    2. Which BP-regulating mechanism(s) can result in the development of
    hypertension if defective (select all that apply)?
    a. Release of norepinephrine
    b. Stimulation of the sympathetic nervous system
    c. Stimulation of the parasympathetic nervous system

    d. Activation of the renin-angiotensin-aldosterone system

    3. While obtaining subjective assessment data from a patient with
    hypertension, the nurse recognizes that a modifiable risk factor for the
    development of hypertension is:
    a. A low-calcium diet.
    b. Excessive alcohol consumption.
    c. A family history of hypertension.

    d. Consumption of a high-protein diet.

    4. When obtaining a health history from a client, which finding is most
    suggestive that the client is hypertensive? (select all that apply)
    a. The client experiences occasional heart palpitations associated with chest

    pain.

    b. The client has experienced fainting episodes.

    c. The client has difficulty sleeping all night.

    d. The client is having pounding headache

    5. Basing on the causes and risk factors, differentiate briefly the essential

    and secondary hypertension.

    6. What are two physiologic components that determine blood pressure?

    7. You are caring for P.N., a 46-year-old man with a history of poorly
    controlled hypertension and chronic kidney disease. You note that he is
    taking the antihypertensive medications. He tells you that he can no longer
    live with the side effects of these drugs (e.g., fatigue, dry mouth, erectile
    dysfunction). He states that he wants to stop taking the medications. He
    believes that if he changes his lifestyle by reducing salt from his diet,
    losing weight, and beginning exercise, he can control his hypertension.
    a. Explain different lifestyle changes you would advise P.N. to practice in
    order to be able to control her hypertension.
    b. P.N. must continue to take her medications. Justify the importance of

    adherence to hypertensive medications.

    8. List all essential needed investigations and their rationale in the

    management of hypertension.

    9. What are the elements that constitute the nursing management of the

    client with hypertension?

    10. List all potential complications of uncontrolled hypertension.

    11. Which manifestation is an indication that a patient is having a hypertensive

    emergency?

    a. Symptoms of a stroke with an elevated BP

    b. A systolic BP >220 mm Hg and a diastolic BP >140 mm Hg

    c. A sudden rise in BP accompanied by neurologic impairment

    d. A severe elevation of BP that occurs over several days or weeks

    12. Discuss the medical and nursing management of the client with

    Hypertensive crisis.

    Case study:

    Carefully read the case scenario below and answer the following

    questions:

    K.J. is a 73-year-old woman with no history of hypertension. She came to the
    clinic for dizziness and chronic headache. She says she has gained 10Kgs over
    the past year. Her father died from stroke. She has never smoked and uses no
    alcohol. She takes one medication (multivitamin). She eats a lot of carbohydrates
    food and does not do exercise because she feels tiredness whenever she wants
    to do exercises. Her vital parameters are: height: 168 cm, weight: 86 kgs, BP:
    190/82 mm Hg Pulse: 82 beats per minute, Temperature: 36.2 degree Celsius,
    Respiratory rate: 18 cycles per minute. During her physical examination there
    are no abnormalities at other systems except BMI and blood pressure that are
    high. She was primarily diagnosed to have primary hypertension while waiting
    for additional investigations.
    1. What are the contributing factors to the development of hypertension was
         K.J. presenting?
    2. What additional information would you need to collect that will help in
        deciding about the medical condition of K.J?
    3. From her condition, what would you advise as investigations to be
        requested that might be helpful in deciding further management of K.J
        medical condition? Justify the rationale.
    4. Discuss all aspects that might be included into her medical and nursing
        management.
    5. If drug therapy became necessary to treat K.J.’s hypertension, give three
         examples of antihypertensive drugs that would be indicated based on her

        clinical status?

    6. Explain the different lifestyles changes would you recommend to K.J.?

    7. If her condition is not well managed, what do you expect as complications?

    2.3 STROKE

    Learning Activity 2.3

    Observe the image below and read carefully the scenario below and

    answer the questions that follow:

    d

    Figure2.5 Patient with left side body functional impairment.

    N.J. is a 66-years-old woman who lives in Kigali. She arrives in the emergency
    department at CHUK after falling down during the night when she tried to get
    up to go to the bathroom. She had history of high blood pressure. She states
    that she fell because she could not control her left leg. Her husband brought
    her to the hospital, but states that it was not possible for him to get his wife to
    the car alone because most of her body parts were not functioning and were
    weak. When arrived at CHUK, she was having paralysis of entire left side of the
    body involving left arm and left leg, inability to sit and stand alone, general body
    weakness, and unable to speak.

    1. Referring to the above situation, what might be the possible cause for her
         left side body functional impairment and general body weaknesses?
    2. What are other additional information you would ask to guide in diagnosing
        the medical condition that patient has?
    3. In general, what are the causes and risk factors do you think can be at the
         origin of that medical problem?
    4. What investigations might you expect to be ordered in order to confirm
        the medical diagnosis?
    5. What will be included into the comprehensive physical assessment of
        N.J?
    6. What is the medical diagnosis is N.J presenting?
    7. What should be included into the treatment plan for N.J?
    8. Identify all possible complications that might result from the medical

         condition of N.J.?

    the brain, with stroke being the most frequent manifestation of cerebrovascular
    disease.
    Brain and cerebral nerve cells are extremely sensitive to a lack of oxygen; if they
    are deprived of oxygenated blood for 3 to 7 minutes, both the brain and nerve cells
    begin to die. Prolonged interruption in the flow of blood and oxygen through one of
    the arteries supplying the brain leads to stroke or cerebrovascular accident.
    A stroke also called cerebrovascular accident occurs when the blood supply to parts
    of the brain is interrupted or reduced, preventing brain tissue from getting oxygen
    and nutrients. A stroke is a medical emergency, and prompt treatment is crucial.
    Early recognition and action can reduce brain damage and further complications.
    Causes, risks factors and pathophysiology
    Genetic risk factors (among non-modifiable risk factors) are important in the
    development of all vascular diseases, including stroke. A person with a family
    history of stroke has an increased risk of having a stroke. Genes encoding products
    involved in lipid metabolism, thrombosis, and inflammation are believed to be
    potential genetic factors for stroke. Modifiable risk factors are those that can be
    altered through lifestyle changing and medical treatment, thus reducing the risk of

    stroke.

    Cerebrovascular disease arises from pathological processes in blood vessels of

    Modifiable risk factors for hypertension are: metabolic syndrome, heart disease,
    heavy alcohol consumption, poor diet, drug abuse, sleep apnea, obesity, physical

    inactivity and smoking.

    Non modifiable risk factors for hypertension are: age, gender, race, heredity/

    family history.

    d

    Strokes are classified on the basis of underlying pathophysiologic findings:
    A. Ischemic (represent 80% of all Strokes): mainly due to thrombus, emboli,
    systemic hypo perfusion, and atherosclerosis. When ischemic strokes occur,
    glucose and oxygen to brain cells are reduced. The reduced glucose quickly
    depletes the stores of adenosine triphosphate (ATP), resulting in anaerobic
    cellular metabolism and the accumulation of toxic products such as lactic
    acid. Although some brain cells die from anoxia, the lack of oxygen destroys

    additional brain cells by a secondary mechanism

    1. Atherosclerotic: Fatty streak is covered by collagen, forming a fibrous
    plaque that appears grayish or whitish, that result in narrowing of vessel
    lumen, and continued inflammation can result in plaque instability, ulceration,
    and rupture, platelets accumulate and thrombus forms, Increased narrowing

    or total occlusion of lumen.

    2. Systemic hypoperfusion: Reduced blood flow is more global in patients
    with systemic hypoperfusion and does not affect isolated regions. The
    reduced perfusion can be due to cardiac pump failure caused by cardiac
    arrest or arrhythmia, or to reduced cardiac output related to acute myocardial
    ischemia, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia
    may further reduce the amount of oxygen carried to the brain.
    3. Thrombotic stroke: Thrombosis occurs in relation to injury to a blood
    vessel wall and formation of a blood clot that result to narrowing of the blood
    vessel. It is the most common cause of stroke. The thrombotic strokes are
    associated with hypertension or diabetes mellitus, both of which accelerate
    atherosclerosis.
    4. Embolic stroke: Occurs when an embolus lodges in and occludes a
    cerebral artery. It is the second most common cause of stroke. Most emboli
    originate in the endocardial (inside) layer of the heart, with plaque breaking
    off from the endocardium and entering the circulation. The embolus travels
    upward to the cerebral circulation and lodges where a vessel narrows.
    Patient with an embolic stroke commonly has a rapid occurrence of severe
    clinical symptoms but warning signs are less common with embolic than with
    thrombotic stroke. Onset of embolic stroke is usually sudden and may or
    may not be related to activity. Patient usually remains conscious, although

    may have a headache.

    f

    B. Hemorrhagic (represent 20% of all Strokes): due to intracerebral
    hemorrhage (ICH) or subarachnoid hemorrhage (SAH). Hypertension is
    the most important cause. This type of stroke results from bleeding into the
    brain tissue itself or into the subarachnoid space or ventricles. Hemorrhage
    commonly occurs during periods of activity. It often has a sudden onset of
    sympt oms, with progression over minutes to hours because of ongoing
    bleeding.
    C. Transient ischemic attack (TIA): It is a transient episode of neurologic
    dysfunction caused by focal brain, spinal cord, or retinal ischemia, without
    acute infarction of the brain. The symptoms last less than one hour and most
    TIAs resolve. We need to encourage patients to consult a health facility at any
    symptom onset/occurrence since once a TIA starts, one does not know if it
    will persist and become a true stroke, or if it will resolve.
    Clinical Manifestations
    Primary assessment focuses on cardiac and respiratory status (ABC: Airway,
    Breathing, Circulation) and neurologic assessment. If the patient is stable, the
    history is obtained as follows: (1) description of the current illness with attention to
    initial symptoms, particularly symptom onset and duration, nature (intermittent or
    continuous), and changes; (2) history of similar symptoms previously experienced;
    (3) current medications; (4) history of risk factors and other illnesses such as
    hypertension; and (5) family history of stroke or cardiovascular diseases. This
    information is gained through an interview of the patient, family members, significant
    others, and/or caregiver.
    Secondary assessment includes a comprehensive neurologic examination of
    the patient. This includes (1) level of consciousness (using the Glasgow Coma
    Scale), (2) cognition; (3) motor abilities; (4) cranial nerve function; (5) sensation; (6)
    proprioception; (7) cerebellar function; and (8) deep tendon reflexes.


    s


    s

    c

    c

    s

    Motor deficits are the most obvious effect of stroke. Motor deficits include impairment
    of (1) mobility, (2) respiratory function, (3) swallowing and speech, (4) gag reflex,

    and (5) self-care abilities.

    Investigations

    When manifestations of a stroke occur, diagnostic studies are done to:
    • Confirm that it is a stroke and not another brain lesion and
    • Identify the likely cause of the stroke.
    Important diagnostic tools for patients who have experienced a stroke are a non
    and/or contrasted computed tomography scan (CT Scan) or magnetic resonance

    imaging (MRI). These tests can rapidly distinguish between ischemic and

    hemorrhagic stroke and help determine the size and location of the stroke.

    d

    The following Blood tests are also done to help identify conditions contributing to
    stroke and to guide in deciding the management: Complete blood count (including
    platelets, coagulation studies: prothrombin time, troponin, international normalization
    rate: INR), Electrolytes (sodium, potassium, calcium, chloride, etc), Blood glucose
    levels, Renal function tests (urea and creatinine), and Liver function tests (ASAT,
    ALAT), Lipid profile, Cerebrospinal fluid analysis. The Electrocardiogram can also

    be performed.

    Adequate Medical Diagnosis

    Stroke is diagnosed through several technics: history taking, and comprehensive
    physical exam that include the neurological examination. Imaging investigations like
    CT scan and MRI are helpful. These imaging are helpful in determining the extent
    of injury and location, therefore determining the causes and subtypes. Laboratory
    investigations are needed to look for other factors that might be associated with

    stroke.

    Treatment Plan

    Hypertension is the single most important modifiable risk factor, therefore it needs

    to be detected early and adequately treated. The goals for collaborative and

    comprehensive management of stroke are:

    1. To prevent secondary brain injury (intracranial hypertension, hematoma
         expansion, elevated intracranial pressure, seizures, herniation )
    2. To maintain and secure the airways (due to paralysis of the pharynx
         muscles),
    3. To provide general body support (vital signs, fluid and electrolyte balance,
         hemodynamic patient monitoring: all Systems to be cared for) and
    4. To anticipate the occurrence of complications (atelectasis, aspiration
         pneumonia, airway obstruction that might require tracheal intubation and
         mechanical ventilation), and plan for Respiratory system management as

         Priority.

    Interventions

    While caring for patient with stroke, the care providers must ensure the following:

    A. Cardiac and Respiratory System:

    • Ensure patent airway, Call for resuscitation team/shout for help, Perform
       pulse oximetry (SP02) and oxygen therapy as urgency to maintain adequate
       oxygenation.
    • Obtain IV access.
    • Monitor and maintain normal BP and other vital signs, and watch for
       hypertension post stroke (Continuous effective monitoring of BP). Eligible to
       thrombolysis: BP≤ 185/110 mmHg before and 180/105 mmHg after for at
       least 24 hours. Blood pressure should not be treated acutely for patients with
       ischemic stroke who are not eligible to thrombolysis, except Hypertension
       is extreme, BP >220/120 mmHg. Intravenous agents are recommended for
       blood pressure lowering, labetalol& nicardipine as first line , IV Nitroprusside
       as second-line therapy.
    • Obtain CT scan or MRI immediately, Perform baseline laboratory tests (FBC,
       Troponin, INR(International Normalization Rate), etc).
    • Proper Positioning of patient head: The appropriate position of the patient
       and the head of bed should be respected to prevent the risk of elevated
       intracranial pressure and aspiration. The head in neutral alignment with the
       body elevation of the head of the bed to 30 degrees are recommended if no
       symptoms of shock or injury occur.
    • Implement anti-seizure precautions and Anticipate thrombolytic therapy for
       ischemic stroke.
    • Adjusting fluid intake to the individual needs of the patient, Regulating IV
       infusions and calculating intake and output, noting imbalance. Fluid and

       electrolyte balance must be controlled carefully: Adequate hydration promotes

    perfusion and decreases further brain injury. Adequate fluid intake during
    acute care via oral, intravenous (IV), or tube feedings should be 1500 to 2000
    mL/day. Over hydration may compromise perfusion by increasing cerebral
    edema.
    • Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) and
      monitoring heart sounds for murmurs.
    • Monitoring and Management of blood glucose levels: Hypoglycemia can
      cause focal neurologic deficits mimicking stroke, therefore check the blood
      sugar and rapidly correct low serum glucose (<60 mg/dL /3.3 mmol/L).
       Hyperglycemia in diabetic patients or stress hyperglycemia is associated with
       poor functional outcome. Hyperglycemia may augment brain injury by several
       mechanisms including increased tissue acidosis from anaerobic metabolism,
       free radical generation, and increased blood brain barrier permeability.
    • Check for fever and other signs and symptoms of infection: Meningitis,
       subdural empyema, brain abscess, and infective endocarditis need to be
       excluded as the etiology of fever if acute neurologic deterioration
    • After stroke, patient is at risk for deep vein thrombosis related to immobility,
       loss of venous tone, and decreased muscle pumping in leg, most effective
       prevention is keeping the patient moving, and encourage ambulation.
    B. Musculoskeletal and Integumentary system: Goal is to maintain optimal
         function:
    • Prevention of joint contractures and muscular atrophy: Range-of-motion
       exercises and positioning are important. Paralyzed or weak side needs
       special attention when positioning.
    • Avoidance of pulling the patient by the arm to avoid shoulder displacement
    • Good skin hygiene, Early mobility, ambulation and Change position of the
       patient because the stroke patient is susceptible to skin breakdown related to
       Loss of sensation, Decreased circulation, Immobility compounded by patient
       age, poor nutrition, dehydration, oedema, and incontinence
    C. Gastrointestinal system:
    • Patients may be placed on stool softeners.
    • Physical activity promotes bowel function.
    • Implement a bowel management program for problems with bowel control,
       constipation, incontinence
    D. Urinary system:
    • Promote normal bladder function.
    • Avoid the use of indwelling catheters as much as you can.
    E. Nutrition:
    • Nutritional needs require quick assessment and treatment.
    • May initially receive IV infusions to maintain fluid and electrolyte balance
    • May require nutritional support
    • First feeding should be approached carefully, and always test swallowing,
    chewing, gag reflex, before beginning oral feeding.
    • Feedings must be followed by oral hygiene.
    • High-fiber diet and adequate fluid intake
    F. Antiplatelet drugs are usually the chosen treatment: Aspirin is the most
        frequently used as antiplatelet agent. Recombinant Tissue plasminogen
        activator: to reestablish blood flow from blocked blood vessel. To be given
        3 to 4.5 hours after signs and symptoms of ischemic stroke. Determining
        eligibility to IV thrombolytic therapy for patients with acute ischemic stroke: IV
        Alteplase is first-line therapy, to be initiated within 4.5 hours of symptom onset
        or the time last known to be well. Oral anticoagulation using warfarin is the
        treatment of choice for individuals with atrial fibrillation.
    G. Surgical interventions might be needed depending on medical diagnosis
         and goal of treatment (eg: hematoma evacuation, removing the plaque,

         opening the blocked artery, anastomosis, etc).


    s

    Preventive Strategies
    1. Teaching patients and families about all Preventive measures (reduce salt
         and sodium intake, Maintain a normal body weight, Maintain a normal blood
         pressure, Increase level of physical exercise, Avoid cigarette smoking or
        tobacco products, Limit consumption of alcohol to moderate levels, Follow a
        diet that is low in saturated fat, total fat, and dietary cholesterol and high in
        fruits and vegetables).
    2. Teaching patients and families about signs and symptoms, stroke
         pathophysiology, complications and when to seek health care for symptoms.
    3. Education about hypertension control and adherence to medication,
         particularly in persons with known risk factors.
    4. Education and management of modifiable risk factors to change lifestyle:
         Patients with known risk factors (Diabetes mellitus, Hypertension, Obesity,
         High serum lipids, Cardiac dysfunction, etc) require close and effective
         management.


    x

    Evolution and Complications
    Stroke is a significant cause of death and disability. The highest incidence of stroke
    occurs among older adults and the people with comorbidities. Stroke can result
    in a profound disruption in the life of a person. The ability to perform activities of
    daily living may require many adaptive changes because of physical, emotional,
    perceptual, and cognitive deficits. There is need to assist the patient and caregiver
    in the transition through acute phase of care, rehabilitation, long-term care, and
    home care. The needs of the patient, the caregiver, and the family involvement
    require ongoing health education.
    The most common complications of stroke are:
    • Brain edema: swelling of brain post stroke
    • Pneumonia: causes breathing problems
    • Swallowing problems: that can potentially cause the aspiration pneumonia
    • Blood clot or deep vein thrombosis: related to limited range of motion/physical
    activity
    • Aphasia and speech disorders

    • Depression and other mood disorders, chronic headache,etc

    Self-assessment 2.3

    1. Indicate whether the following manifestations of a stroke are more likely
        to occur with right brain damage (R) or left brain damage (L).
    a. Aphasia
    b. Impaired judgment
    c. Quick, impulsive behavior
    d. Inability to remember words
    e. Neglect of the left side of the body
    f. Hemiplegia of the right side of the body
    2. Four days following a stroke, a patient is to start oral fluids and feedings.
         Before feeding the patient, what should the nurse do first?
    a. Check the patient’s gag reflex.
    b. Order a soft diet for the patient.
    c. Raise the head of the bed to a sitting position.
    d. Evaluate the patient’s ability to swallow small amounts of crushed ice or
          ice water.
    3. What is the priority intervention in the emergency department for the
         patient with a stroke?
    a. Intravenous fluid replacement
    b. Administration of osmotic diuretics to reduce cerebral edema
    c. Initiation of hypothermia to decrease the oxygen needs of the brain
    d. Maintenance of respiratory function with a patent airway and oxygen
         administration
    4. What is the difference between ischemic and hemorrhagic stroke?
    5. Describe different criteria that are assessed to determine the level of
         consciousness using Glasgow coma scale
    6. List the preventive strategies of stroke for (1) healthy people and
         overweight people, and (2) patient with hypertension and diabetes.
    7. What therapeutic options are available for the patient with a hemorrhagic

        and ischemic stroke?

    Case study

    Carefully read the case study below and answer the following questions:

    R.C., a 52-year-old married man, was admitted to the hospital with unconscious
    after his family find that he could not wake up in the morning. He was accompanied
    by his wife and one daughter 20 years. He had history of hypertension with poor
    adherence on captopril and had overweight. He complained of severe headache
    associated with epistaxis the day before he became unconsciousness. Vital
    signs at arrival at hospital: BP 198/102 mmHg, RR 16 cycles/minute, HR 74
    bpm, Temp 36.7°C, SPo2: 82% on room air. His Glasgow Coma Scale score:
    9/15. He is not able to open the mouth, unable to sit or stand without support,

    and has right sided hemiplegia. Blood sugar: 94 mg/dl.

    Questions:

    1. What will be additional information you will ask the family members to

    guide in deciding about the diagnosis and the management?

    2. What investigations will you advise to be requested to determine the
    cause of R.C. unconsciousness? What is the rationale of requesting

    those investigations?

    3. List all nursing interventions that have the highest priority for R.C. at this

    stage of his illness?

    4. What should the family be told to expect in terms of R.C. medical

    condition

    2.4 END UNIT 2 ASSESSMENT

    End of unit 2 assessment

    SECTION A: Short Answer Questions

    1. Cardiac output is the product of ……………………….. multiplied
         by…………………………..
    2. Prolonged hypertension can cause significant damage to these four
    “target organs”: A)………………… B)…………………………….,
    C)…………………………, and D)………………..
    3. Discuss in detail several hypotheses about the pathophysiologic basis for
         elevated blood pressure.
    4. Explain how lifestyle changes and medications can control, not cure,
         hypertension.
    5. Compare and contrast the different medications used to treat hypertension
         and the associated nursing considerations.
    6. Compare and contrast a hypertensive crisis with a hypertensive
         emergency.
    7. List four non modifiable risk factors for stroke.
    8. Compare the etiology and symptoms of two types of stroke: ischemic
         stroke and hemorrhagic stroke.
    9. Describe the focus of nursing interventions when helping a patient recover

         from an ischemic stroke.

    10. Identify the significance of the following laboratory test results when found

    in patients with hypertension:

    s

    11. A 42-year-old man has been diagnosed with primary hypertension with
    an average blood pressure of 162/92 mm Hg on three consecutive clinic
    visits. What are four priority lifestyle modifications that should be explored

    in the initial treatment of the patient?

    12. Identify two medical therapies that are specific to each of the following

    types of shock.

    w

    SECTION B: Multiple Choice Questions

    1. After taking vital signs, you write down your findings as temperature of
    36.6 degree Celsius, Pulse of 66 beats per minute, respiratory rate of 18
    cycles per minutes, Blood Pressure of 124/82 mmHg. Which of these

    numbers represents the systolic blood pressure?

    a. 36.6

    b. 124

    c. 82

    d. 66

    2. Stroke volume of the heart is determined by:
    a. The degree of cardiac muscle strength (pre-contraction).
    b. The intrinsic contractility of the cardiac muscle.
    c. The pressure gradient against which the muscle ejects blood during

    contraction.

    d. All of the above factors.

    3. The most important factor in regulating the caliber of blood vessels, which

    determines resistance to flow, is:

    a. Hormonal secretion.

    b. Independent arterial wall activity.

    c. The influence of circulating chemicals.

    d. The sympathetic nervous system.

    4. Stage 1 hypertension is defined as persistent blood pressure levels in
    which the systolic pressure is higher than …………. and the diastolic is

    higher than …………….

    a. 110/60 mm Hg
    b. 120/70 mm Hg
    c. 130/80 mm Hg

    d. 140/90 mm Hg

    5. Georgia, a 30-year-old woman, is diagnosed as having secondary
    hypertension when serial blood pressure recordings show her average
    reading to be 170/100 mm Hg. Her hypertension is the result of renal
    dysfunction. The kidneys help maintain the hypertensive state in essential
    hypertension by:
    a. Increasing their elimination of sodium in response to aldosterone secretion.
    b. Releasing renin in response to decreased renal perfusion.
    c. Secreting acetylcholine, which stimulates the sympathetic nervous system
         to constrict major vessels.
    d. Doing all of the above.
    6. The first priority of treatment for a patient with altered level of consciousness
         is:
    a. Assessment of pupillary light reflexes.
    b. Determination of the cause.
    c. Positioning to prevent complications.
    d. Maintenance of a patent airway.
    7. The degree of neurologic damage that occurs with an ischemic stroke
         depends on the:
    a. Location of the lesion.
    b. Size of the area of inadequate perfusion.
    c. Amount of collateral blood flow.
    d. Combination of the above factors.
    8. The initial diagnostic test for a stroke, usually performed as emergency is:
    a. 12-lead electrocardiogram.
    b. Carotid ultrasound study.
    c. Non contrasted computed tomogram.
    d. Transcranial doppler flow study.
    9. How is secondary hypertension differentiated from primary hypertension?
    a. Has a more gradual onset than primary hypertension
    b. Does not cause the target organ damage that occurs with primary

         hypertension

    c. Has a specific cause, such as renal disease, that often can be treated by
         medicine or surgery
    d. Is caused by age-related changes in BP regulatory mechanisms in people
         over 65 years of age
    10. What is most organ damage in hypertension related to?
    a. Increased fluid pressure exerted against organ tissue
    b. Atherosclerotic changes in vessels that supply the organs
    c. Erosion and thinning of blood vessels from constant pressure
    d. Increased hydrostatic pressure causing leakage of plasma into organ
          interstitial spaces
    11. A 38-year-old man is treated for hypertension with triamterene and
           hydrochlorothiazide and metoprolol. Four months after his last clinic
           visit, his blood pressure returns to pretreatment levels and he admits he
           has not been taking his medication regularly. What is the nurse’s best
           response to this patient?
    a. “Try always to take your medication when you carry out another daily
           routine so you do not forget to take it.”
    b. “You probably would not need to take medications for hypertension if you
           would exercise more and stop smoking.”
    c. “The drugs you are taking cause sexual dysfunction in many patients. Are
           you experiencing any problems in this area?
    d. “You need to remember that hypertension can be only controlled with
           medication, not cured, and you must always take your medication.”
    12. What does the nursing responsibility in the management of the patient
           with hypertensive urgency often include?
    a. Monitoring hourly urine output for drug effectiveness
    b. Titrating IV drug dosages based on BP measurements every 2 to 3 minutes
    c. Providing continuous electrocardiographic (ECG) monitoring to detect side
         effects of the drugs
    d. Instructing the patient to follow up with a health care professional within 24

         hours after outpatient treatment

    13. What is included in the correct technique for blood pressure
            measurements?
    a. Always take the BP in both arms.
    b. Position the patient supine for all readings.
    c. Place the cuff loosely around the upper arm.
    d. Take readings at least two times at least 1 minute apart.
    14. A patient comes to the emergency department immediately after
           experiencing numbness of the face and an inability to speak but while
           the patient awaits examination, the symptoms disappear and the patient
           requests discharge. Why should the nurse emphasize that it is important
           for the patient to be treated before leaving?
    a. The patient has probably experienced an asymptomatic lacunar stroke.
    b. The symptoms are likely to return and progress to worsening neurologic
           deficit in the next 24 hours.
    c. Neurologic deficits that are transient occur most often as a result of small
           hemorrhages that clot off.
    d. The patient has probably experienced a transient ischemic attack (TIA),
    which is a sign of progressive cerebrovascular disease.
    15. What are characteristics of a stroke caused by an intracerebral hemorrhage
          (select all that apply)?
    a. Carries a poor prognosis caused by rupture of a vessel
    b. Strong association with hypertension
    c. Commonly occurs during or after sleep
    d. Creates a mass that compresses the brain
    16. A patient is admitted to the hospital with a left hemiplegia. To determine
          the size and location and to ascertain whether a stroke is ischemic or
          hemorrhagic, the nurse anticipates that the health care provider will
    request (select all that apply):
    a. Lumbar puncture.
    b. Cerebral arteriogram.
    c. Magnetic resonance imaging (MRI).

    d. Computed tomography (CT) scan with or without contrast.

    17. Which intervention should the registered nurse delegate to the associate
           nurse when caring for a patient following an acute stroke?
    a. Assess the patient’s neurologic status.
    b. Assess the patient’s gag reflex before beginning feeding.
    c. Administer ordered antihypertensives and platelet inhibitors.
    d. Teach the patient’s caregivers strategies to minimize unilateral neglect.

    18. What is the key factor in describing any type of shock?
    a. Hypoxemia
    b. Hypotension
    c. Vascular collapse
    d. Inadequate tissue perfusion

    19. Which hemodynamic monitoring description of the identified shock is
    accurate?
    a. Tachycardia with hypertension is characteristic of neurogenic shock.
    b. In cardiogenic shock the patient will have an increased pulmonary artery
    wedge pressure (PAWP) and a decreased cardiac output (CO).
    c. Anaphylactic shock is characterized by increased systemic vascular
    resistance (SVR), decreased CO, and decreased PAWP.
    d. In septic shock, bacterial endotoxins cause vascular changes that result in
    increased SVR and decreased CO.

    20. As the body continues to try to compensate for hypovolemic shock, there
    is increased angiotensin II from the activation of the renin-angiotensinaldosterone
    system. What physiologic change occurs related to the
    increased angiotensin II?
    a. Vasodilation
    b. Decreased blood pressure (BP) and CO
    c. Aldosterone release results in sodium and water excretion

    d. Antidiuretic hormone (ADH) release increases water reabsorption

    21. Progressive tissue hypoxia leading to anaerobic metabolism and
    metabolic acidosis is characteristic of the progressive stage of shock.

    What changes in the heart contribute to this increasing tissue hypoxia?

    a. Arterial constriction causes decreased perfusion.
    b. Vasoconstriction decreases blood flow to pulmonary capillaries.
    c. Increased capillary permeability and profound vasoconstriction lead to the
         increased hydrostatic pressure.
    d. Decreased perfusion occurs, leading to dysrhythmias, decreased CO, and

         decreased oxygen delivery to cells.